Part II follows, as continued from my previous Part I post on the topic, which includes my long path to obtaining and maintaining my IBCLC credential, and also includes why I believe a lesser credential as a "stepping stone" can only hurt the IBCLC, UNLESS we become so very overworked that all or nearly all IBCLCs beg IBLCE to create the lesser credential to help us with an excessive workload.  That will not happen in my lifetime because our specialty is such a narrow one.     

Continuing from Part I:  

In January 1998, I traveled four hours from my home in Elkins, West Virginia to Bethesda, Maryland to take Vergie Hughes' 40-hour on-site program through Lactation Education Resources, incurring all my own expenses for the week's training, lodging, food, and gas, while still employed by WIC at $5.52 per hour. It was a week rich in content and professionalism - - there were 114 of us, including 4 attendees who were from outside the U.S. My most treasured memory from that week is of listening to Miriam Labbok speak about LAM.

After that week's training, I continued working for WIC at $5.52 per hour for 15 to 20 hours each week, documenting my hours for the IBLCE exam application later that year, while still supplementing my WIC income elsewhere as an RN. Even after 2 1/2 years with WIC (there was no other paid lactation work in the seven county area), I was still lacking nearly 500 hours toward IBLCE's then-requirement of 2,500 lactation-specific clinical hours in order to register to take the IBLCE exam that summer. It was agonizing to think that I would need to wait yet another year to sit the IBLCE exam in order to complete all of the required hours, so I called Vergie Hughes' office to discuss other ways that I might get these necessary hours in order to take the IBLCE exam that year. When her secretary advised me that a 100-hour supervised clinical internship was equivalent to 500 hours of unsupervised practice, I scheduled the internship with Vergie and completed the necessary clinical hours in order to register for the 1998 IBLCE exam, again incurring my own expenses for the internship. 

There were only three registrants to take the exam that year from West Virginia, and we were given two locations to choose from for taking the exam: either Pittsburgh, Pennsylvania or Falls Church, Virginia. I chose the latter location, and am pretty sure that I was the happiest person in the IBLCE exam room in Falls Church that year.

After receiving my IBCLC credential that fall, my strategy for employment was to continue working with WIC while also serving non-WIC families as an IBCLC, planning to travel to surrounding counties as needed. Three months later, I spent my tax return on a $999.00 BabyWeigh scale, still ignorant that Tanita made the identical product for nearly half the cost. One of the highlights of working in that small town was the opportunity to work with Mary Boyd, a pediatrician who was the Breastfeeding Coordinator for the state chapter of the AAP for decades. At the other end of the spectrum, that little town had only one other pediatrician then, whose medical management of lactation-related concerns was utterly abysmal, and there's no need to elaborate on that in this forum. I continued to work as an RN outside of lactation, while still working for WIC at $5.52 per hour, 15 to 20 hours per week, and continued to offer private lactation consults which were few and far between due to the small population (the population of Elkins WV is 7,200 - - it's the largest town in the county as the county seat in Randolph county, and the highest proportion of childbearing families are also covered by Medicaid there). I set my private consult fee in 1999 at $36 per hour ($9 per 15-minute increment), which was considered exorbitant by some in the community, although the supportive pediatrician felt I should set my fee much higher, comparable to a nurse practitioner's rates by charging similar to her PNP's rates in 15-minute increments (had I done so, I would have priced myself out of existence in that poor state, since a lactation consult would RARELY be completed in 15 minutes). The great majority of births in West Virginia are covered by Medicaid, as is the case here in Florida, where I currently live, and West Virginia Medicaid did not and likely does not reimburse for IBCLC services.

So I primarily worked for West Virginia WIC in the first five years of my lactation career (1995-2000), then was fortunate to find a prn IBCLC position at a small hospital in D.C. (1,800 births annually, Level III nursery) where I was elated to work an 8 to 12-hour shift every Friday, as well as one weekend a month, and did that from 2000 - 2004. In 2001, I also found an additional inpatient prn position in a northern Virginia hospital 45 minutes from D.C., and also worked there one to 2 days a week as needed. I was then living in Winchester, Virginia and couldn't ever afford to live in D.C., driving the minimum 3-hour round trip commute solely out of the desire to be busy in this field that I love. To put bread on the table during those four years as a self-supporting solo member of my household, I also taught two sibling readiness classes per month at Winchester Medical Center in Winchester, Virginia (they had just hired their second IBCLC before I moved there in 2000 and did not see a need for another IBCLC at that time), and I also found a pediatric practice in Winchester of five peds docs who were willing to have me come in for up to two hours maximum daily, which ranged from one day a week up to two days a week maximum at $20 per hour. During that four year stretch of living on the most narrow of budgets, I also had a private practice which was nearly nonexistent due to the long-standing practice at Winchester Medical Center of offering FREE outpatient lactation consults. How many outpatient practices in physical therapy, speech therapy, and occupational therapy could survive when competing against free outpatient services offered by their inpatient peers? It was an exceedingly difficult time financially, but I stayed in the field due to my devotion to our profession and the families we serve, as well as devotion to the science of breastfeeding and human lactation.

In 2003, while I was still living in Winchester, Virginia and commuting to the two hospitals (one in D.C., the other in northern Virginia), I attended an open house of a lovely new private lactation practice that had opened in Ashburn, Virginia. The IBCLC who opened that solo office practice had spent the previous 12 years of her well-regarded lactation career providing home visits in D.C. and northern Virginia. At the 12-year mark, she made the decision to open an office practice in addition to her home visit practice, and took out a mortgage on office space in a new office development located beside dental offices, etc. In giving me a tour of her office space, she explained her rationale for taking out the mortgage was that if her office practice couldn't survive in that setting, she would be able to readily sell the property in that bedroom community to D.C.
By 2005, I was elated to find a full-time IBCLC position at a large hospital in northern Virginia, just outside of D.C. - - 12,000 births a year (!) and of course a Level III nursery. I still couldn't afford to move into that area, but I did move in 30 minutes closer to shorten my commute, to Ashburn, Virginia. In the same time period as I was relocating to Ashburn, I heard that the private lactation practice based in Ashburn had closed, and that the IBCLC had gotten an inpatient position that had just opened up at Winchester Medical Center. Her former office space in Ashburn then sat empty for several years through the worst of the recession that began in 2007 - 2008. Prior to her departure from Ashburn, that IBCLC had a lovely boutique within her well-appointed office, and she offered childbirth and other parent-child classes as well. In my opinion, that IBCLC did everything she could have to survive financially, and I repeat that she was and is well-regarded as an IBCLC. To my knowledge, she continues working as an inpatient IBCLC.

In 2008, after being one of only 3 full-time IBCLCs at the large hospital in northern Virginia (12,000 births/yr), I started working for the oldest outpatient lactation practice in Washington, D.C., and worked there from 2008 - 2012. During those years, clients were advised that payment was expected at the time of service, and at the end of every consult, we gave our clients insurance claim forms to submit to their insurers for reimbursement. During that time, Aetna was the only insurance company well-known for pre-authorizing up to two outpatient lactation consultations, in addition to unlimited inpatient lactation consults, and Aetna clients reportedly could request pre-authorization for more than two outpatient lactation consults as needed. Today, that practice's website states that they are in-network providers with both Aetna and United, and that those with other health insurance will receive a claim form to submit for reimbursement. According to their website today, that practice is also now offering consults on a sliding scale, and also offers WIC clients one complimentary consult.

When the Affordable Health Care Act was being crafted, the AAP worked very hard behind the scenes for covered services by IBCLCs. I would love to hear from those currently in private practice: Do you directly bill any and all insurance companies with a reasonable hope of timely reimbursement? I have a core fear that a stepping-stone credential will have an extremely negative effect on the ability of private IBCLC practices to survive, particularly if in competition with lesser credentialed professionals.

Whether we're providing inpatient or outpatient services or both, we still must refer to a nurse practitioner or a physician when there are signs & symptoms of one or more conditions requiring an antibiotic or antifungal; when a condition such as ankyloglossia requires a hoped-for frenotomy; when a baby presents with markedly asymmetrical facial features and cannot transfer even minimally adequate volumes, and therefore requires a referral to a craniosacral therapist, etc.

What percent of IBCLCs in the U.S. can make a living in the lactation field as the only member of their household? I know something about these profound challenges, having come from a rural state and having single-parented my two children for many years without child support. As a small-town musician, I played church services, weddings and funerals, etc. for many years in order to supplement my modest income as a community-based registered nurse, with an outpatient nurse salary that is typically half of an inpatient nurse's salary.  I chose lesser-paying outpatient work in order to avoid rotating to inpatient night shifts, out of concern about finding someone I could trust to stay overnight with my children. 

I've had the privilege of working with many wonderful LCs over the years, and know that the great majority of my lactation and nurse colleagues were partnered and sharing household expenses. One IBCLC has also mentioned the challenges of living in New York City with a private lactation practice, albeit with a spouse who has ample income.  Lactation consulting is not a straightforward way to make a living for many IBCLCs in the U.S. at present, and until the majority of us agree that we are so chronically overworked, with ample reimbursement for our skill set and time spent, that we are begging IBLCE to provide a lesser credentialed stepping stone as a way to help us meet the need, then the lesser credential has only the potential to hurt the IBCLC. 

An expanded credential - - please, IBLCE, give us that, and generate more income for your credentialing body by doing so. The university-based approach would be ideal for this. I would like to think that before I die, that I could diagnose and treat candidiasis and mastitis in helping to quickly improve the quality of life for nursing dyads, rather than the current state of so many instances of prolonged suffering until a correct diagnosis with appropriate treatment is finally provided by a nurse practitioner or physician somewhere, when that indeed is the case - - if early cessation of the entire breastfeeding course has not already occurred before appropriate treatment is received by one or both members of the dyad.

The perspective from IBLCE staff is and has been one of a large urban perspective, since they've been based in northern Virginia, immediately adjacent to D.C. for nearly all of their existence. This urban perspective is myopic at best in regard to how those of us elsewhere in the U.S. might hope to keep home and hearth together, in spite of a capable intellect, a high level of professionalism, and a strong work ethic. 

With kind regards from a U.S.-based clinician, 

Debra Swank, RN BSN IBCLC
Ocala, Florida USA
More Than Reflexes Education
http://www.MoreThanReflexes.org

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